• In the majority, incontinence occurs only at night (nocturnal enuresis or “bedwetting”); a smaller group also is incontinent during the day (diurnal enuresis).
• Primary enuresis: Continence is never achieved.
• Secondary enuresis: Incontinence recurs after a dry period of at least 6 months.

• For primary nocturnal enuresis (PNE), several theories, with different mechanisms probably playing greater or lesser roles in specific individuals
  • A maturational delay of neurodevelopmental processes, with bladder emptying at lower volume secondary to smaller functional bladder capacity
  • Other studies suggest that decreased secretion of ADH at night causes some patients to produce urine at the same rate night and day, compared with dry peers, who have decreased rates of urine production at night, due to an increase in ADH secretion.
  • Abnormalities of sleep have not been proven to play a role.
• Daytime wetting may be related to detrusor muscle instability, reflux of urine into the vagina with back-seepage after voiding, giggle incontinence, and poor toileting habits.
• Underlying medical or surgical causes are much less common in primary than secondary enuresis.

• Seventy percent of children with enuresis have a parent who was enuretic.
• If both parents were enuretic, 77% of children are enuretic.
• If one parent was enuretic, 43% to 47% of children are enuretic.
• If neither parent was enuretic, only 15% of children are enuretic.
• Incidence in monozygotic twins is twice the incidence in dizygotes

• Twenty percent of children have primary nocturnal enuresis at age 5 years, 10% at age 7 years, and 5% at age 10 years; primary nocturnal enuresis persists in approximately 1% of adults.
• Daytime wetting occurs in only 1% of 7- to 12-year-olds.
• Nocturnal enuresis is two to three times more common in males; daytime wetting is more common in females.

• Prognosis is very good, even without treatment.
• The spontaneous cure rate is 15% per year.

• Urinary tract infection
• Diabetes mellitus
• Diabetes insipidus
• Sickle cell disease
• Structural genitourinary tract defects, including ectopic ureter, ureteral duplication, neurogenic bladder
• Spinal cord pathology
• Constipation
• Excessive caffeine, methylxanthines or other medications
• Any condition causing polyuria can present as enuresis.

• Onset (primary versus secondary)
• When it occurs—nighttime, daytime, or both—and how often
• Toileting habits, frequency of voiding and stooling
• Pattern of urination: dribbling, dysuria, hesitancy, urgency (suggest structural defects, dysfunctional voiding, UTI)
• Associated signs and symptoms: stool incontinence, polydipsia, polyuria
• History of other medical problems, including UTIs
• Behavioral/developmental history: age milestones obtained, toilet training methods, behavioral problems
• Medications (especially caffeine or medications with diuretic effects)
• Typical fluid intake (looking for excessive intake in evening)
• Recent environmental stressors (if secondary enuresis)
• Effect of enuresis on child: Does child sleep over with friends or at camp? Is child teased at school?
• Parents’ attitude toward the problem
• Family history of enuresis? If positive, is the child aware?
• Family history of other diagnoses in differential
• Treatments (or punishments) attempted

• Vital signs and growth parameters
• Abdominal examination to rule out masses, renal enlargement, palpable bladder, constipation
• Genitalia: irritation, adhesions, rash, or other signs of constant dampness; balanitis; stenosis; foreign bodies; trauma
• Observe voiding for character of stream, dribbling
• Rectal: perianal sensation, anal sphincter tone, impaction
• Palpate spine for bony defects and cutaneous signs of underlying spinal defects.
• Neurologic: deep tendon reflexes, gait, strength and tone of lower extremities

• Urine for specific gravity, urinalysis (especially glucose), microscopic examination and culture to exclude UTI, diabetes mellitus, and diabetes insipidus. In the majority of cases, this is the only investigation needed
• If there is a history of UTIs, voiding abnormalities, or voiding symptoms, a voiding cystourethrogram and renal ultrasound should be performed to rule out anatomic defects. The plain scout film can also show constipation or vertebral bony anomalies.
• If findings are suggestive of neurologic dysfunction, urodynamic studies should be performed.

• Treat any underlying condition.
• Education, reassurance, and support
• Avoid punishment.
• Encourage positive reinforcement: praise, star charts, and so on.
• Avoid aggressive therapy in those less than 7 years old.
• Fluid restriction in the evenings is unproven but logically appealing.
• Retention training/bladder stretching exercises are controversial
• Alarm systems: most effective and most cost effective of all interventions; require several weeks to months to achieve complete dryness
• Desmopressin (DDAVP): remains controversial but is used in PNE when other therapies fail, if use can be monitored appropriately
  • Response is generally quick, but enuresis recurs in most subjects after the medication is stopped.
  • Concerns remain regarding potential for hyponatremia and volume overload.
  • Not recommended in children less than 9 years of age
  • Expensive
• Imipramine: useful but potentially lethal if used inappropriately
  • Prescribe only nonlethal quantities to prevent accidental ingestions.
• Oxybutynin: may be useful in the small population of patients with documented detrusor instability
• Night waking exercises and other behavior modification techniques may also be useful in some patients.

• Timely and regular phone follow-up to answer questions, assess progress, and offer encouragement
• See the patient in the office in 1 month if medications are begun.

• Remember the natural course of the symptoms, and balance the use of potentially dangerous medications (if used inappropriately) against the social/emotional impact on the individual.
• Do not overdo laboratory studies: Balance risks and costs with the likelihood of yield. Extensive work-up of isolated PNE seldom yields an organic etiology; work-up should generally be limited to examination of the urine.

Q: Isn’t DDAVP dangerous? What about hyponatremia and volume overload?
A: While the most common side effects noted with DDAVP have been headaches, abdominal pain, and nasal stuffiness, concern remains regarding the potential for hyponatremia and water intoxication. While studies show a safe side-effect profile, there have been scattered reports of serious side effects. Use of DDAVP needs to be monitored carefully, especially since the significance of variations in ADH levels is unclear in the pathophysiology of PNE.

Q: Won’t enuresis recur when DDAVP is stopped?
A: While a significant number of children respond to some degree at the initiation of treatment, results of long-term response to prolonged medication use have varied from study to study. In most instances, long-term cure rates have been only slightly better than spontaneous cure rates.

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